ࡱ > / bjbj\\ >bh>bhf ) R R R R R f f f 8 D < f f D . $ $ ! e$ R R & & @ R R R R t l l l R R R R l R l l l _ v l p 0 l s% s% l s% R l R R l R R R R R R R R R R R R s% R R R R R R R R R X : Patients Name: Preferred Name: Gender: Sex (if different than gender identity): Pronoun: Birth Date: Age: Home Phone Number: Cell Number: Mailing Address: Civic Address: Postal Code: Employed By: Work Number: Email Address: Do you want us to communicate by email/text? Yes FORMCHECKBOX No FORMCHECKBOX Emergency Contact: Phone Number: Do You Have Dental Insurance? Yes FORMCHECKBOX No FORMCHECKBOX Insurance Provider: Policy # Certificate/ID # Medical History Physicians Name: Approx. Date of Last Dental Exam: Please list ALL medications you are taking: None FORMCHECKBOX or List: Do you, or have you had, an allergic or unusual reaction to any drugs or medications? No FORMCHECKBOX Yes FORMCHECKBOX If Yes, to what? Do you have an allergy to latex? No FORMCHECKBOX Yes FORMCHECKBOX Do you have or have you ever had any of the following? Please indicate yes or no Heart Condition Kidney trouble Sinus Problems High Blood Pressure Diabetes Thyroid Disease Smoker Low Blood Pressure Tuberculosis Asthma Other Epilepsy Unusual reaction or allergy to freezing Rheumatic Fever Stroke STD Arthritis Hepatitis A / B / C HIV / AIDS Cancer Excessive bleeding Nervous Disorder Anemia Ulcer Jaw/Facial Fractures or Surgery Persistent coughs Are you Pregnant? Not applicable FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX (How far along?) Please describe any current medical treatment, impending operations, or any other medical or dental information that may possibly affect your dental treatment. Signature: _____________________________ Date: Please note that we require a notice of 24 hours to cancel appointments, or a charge will be added to your account. 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